Should I have a prostate biopsy?
Posted , 74 users are following.
Introduction
I’m 70 and have a PSA which was at 4.6 when I was 66, and while it has been regularly monitored over the past 18 months or so has been moving up and down between 6 and 7. My doctor thought that I should be referred and I have had two hpital appointments, but I have so far decided against having a prostate biopsy, though it is obvious that my local hospital’s oncology department would like me to have one. The health worker I saw at my first hospital appointment was happy to discuss the issue with me, but I suspect the consultant I just saw probably thought I should stop wasting his time and get booked in for a biopsy without further delay.
I have received information from those two appointments, but I have obtained much more information from online research. Based on studying a number of online medical reports over the period 2008 – 2014, it is evident that there is increasing prejudice, at least in the US and Australia, against the use of prostate biopsies. The primary reasons for this seem to be an increasing risk of serious infections from the most common type of biopsy, a growing recognition (though this may be controversial) that psa screening and biopsies are ineffective in reducing the incidence of terminal prostate cancer, and that screening and biopsies contribute to massive ‘over treatment’ of prostate cancers
Summary of Statistics (some of which may be controversial but all of which are based on (my interpretation of) studies published in urological journals, research reviews and conference speeches by leading urologists).
Of every 100 men who have a prostate biopsy:
· 97 didn’t need it (that is, they don’t have a prostate cancer requiring treatment)
· 6 will get a serious infection as a result (a figure which has doubled in recent years), which will cause them to be hospitalised, and from which a very occasional man will die, while others (we don’t know how many) will have persistent painful side effects
· between 17 and 22 will be offered treatment that they don’t need, as a result of which about 25% of men in their 70s will become incontinent or impotent.
The Perceived Indicators for Biopsy
Primarily a raised psa; a psa which has increased rapidly over a fairly short period, typically a year; smoking; family history of prostate cancer; age (considered with the other factors). I have a raised psa, but it’s not dramatically high – it’s been between 6 and 7 over the past 1 ½ years, and it has not increased dramatically – it was 4.6 five years ago. I do smoke, and I am 70, but I am generally in good health, and there is no history of prostate cancer in my family that I know of.
Statistics Based on Recent Urological Papers
Of every 100 men who have a biopsy, between 75 and 80 have no cancerous cells and didn’t need the procedure; 20 to 25 will have cancerous cells found on biopsy BUT a large percentage of these men will have a tumour which develops very slowly, will not be terminal and doesn’t really need any treatment. Only a small percentage will have an aggressive tumour requiring immediate intervention; the Harvard School of Public Health, in a 2014 paper, put this percentage at 10 – 15%, or 3 men out of the 100.
This means only 3 out of every 100 men who have a biopsy really needed it. And there are two other real concerns.
1. The one certainty with prostate biopsies is that 100% of the men who have them will have ‘side effects’. Some will be shortlived and not really a problem, but some will be painful and longer lasting, and some men, currently about 6 out of the 100, will be hospitalised with serious infections, and the very occasional one will die. There are no statistics for the number of men receiving treatment for post-biopsy infections at doctors’ surgeries. I don’t necessarily see this as a reason not to have a biopsy, because obviously if you really need a biopsy to diagnose a terminal cancer then it’s worth putting up with the side effects. But do you really need it?
2. Most worryingly, doctors apparently can’t tell from the biopsy result whether cancerous cells denote an aggressive tumour which requires immediate treatment, or a slow developing tumour which probably does not need any treatment. As a result, as I understand it, all patients with cancerous cells may generally be assumed to need immediate treatment, such as hormone replacement, radiotherapy, chemotherapy, even though 85-90% of them don’t need any treatment. Research papers suggest that in men in their 70s, 25% who have this treatment will become incontinent or impotent as a result. Many of these men will suffer these consequences despite the fact that they didn’t ever need the treatment they were subjected to.
It’s also worrying that at two hospital appointments the issue of what happens after the biopsy has not been raised, even though it was clear that both the people I saw thought I should have a biopsy. Maybe they would say that it would have been raised if and when I agreed to a biopsy, but given concerns about receiving unnecessary treatment, I feel it should have been raised at the time the issue of having a biopsy was raised. Would they have explained to me that if cancerous cells were found, they might not be able to tell whether I needed treatment or not? Would they have told me that there was a risk (if not a certainty?) that I would be ‘offered’ treatment that I might not need? Since they did not have that conversation with me I cannot answer those questions.
Conclusions
My psa is raised but not highly raised and it didn’t move up fast, so I feel it is not at present a firm indicator of the need for a prostate biopsy – it’s inconclusive. The only additional risk factor I have is that I smoke, and I suspect that is often overplayed by the NHS. According to NHS statistics, I should be suffering the ill effects of smoking by the age of 70, in the form of early signs of lung cancer, but when I had a chest scan a year ago it was clear. In addition I have an enlarged prostate – which was determined at my first hospital visit not to feel cancerous – which means I would have a heightened psa anyway.
I have been offered another appointment by the hospital in six months, and I am going to take that up, but unless things change I think that has to be the last for the moment. It’s pointless me trooping up to the hospital every six months when I don’t want a biopsy – which is all they can do by way of diagnosis – and there could be people with aggressive tumours urgently needing those appointments. So I need to decide over the next six months finally, whether I am going to have a biopsy or not.
The hospital has asked me to have another psa blood test before I go for the 6 month appointment, but I have asked my GP for three-monthly psa tests, so that I can get more of a feel for movement on the results before I go for the hospital appointment. If my psa is suddenly moving up rapidly over the next six months, then, depending how fast and how far it is moving, I may agree to a biopsy. Otherwise it is unlikely that I will, in which case there is not much point in the hospital continuing to see me – though I will ask my local surgery to continue monitoring me with 4 or 6-monthly psa tests.
At the age of 70 I still work full-time (for myself), and having unnecessary treatment for prostate cancer would certainly have far more of an impact on my life than having a slow developing prostate cancer which would not affect my health or life expectancy, and might even have more of an impact in the short term than having an aggressive prostate tumour. So it’s a numbers game. None of us is going to live forever, and at my age quality of life is more important than lifespan. Younger doctors especially often don’t take account of this, and assume that keeping you breathing, no matter what state you are in, is some sort of medical triumph. Not surprisingly, there are lots of older people who don’t see it that way!
15 likes, 312 replies
terryw
Posted
Hi steadyeddy
You've gone way beyond my level of expertise! I didn't go ahead with a biopsy, but I'm also fortunate not to have any symptoms, which is partly why I didn't have a biopsy! Plus an oncologist told me that my 4.6 psa at 66 could have been an indication of a tumour, in which case, at about to turn 73, I would most likely be dead had it been aggressive. So obviously not!
I regret I don't have the experience to help you, but I know there are many other people posting here who will be able to, and I wish you all the best and hope you'll post again on your progress.
All the best
terryw
Posted
Hi Charles
Thanks for coming back. I don't blame you for not wanting to have a whole series of biopsies - I decided not to bother with the first one! Basically it doesn't matter to me if I have pca. It's just cells, and we have many different kinds of cells in our bodies. If these cells don't appear to be about to kill me I'm really not bothered about them.
But not everyone sees it that way, and as you say, we all have to make our own decisions. When I first started researching pca, I came across a conference presentation from a leading prostate specialist who told an audience of oncologists: "Prostate cancer is the condition where the cure is worse than the disease."
Guest terryw
Posted
Hi terryw and Vermont007, well as you both asked me to update you with my biopsy results, and how the biopsy procedure was, here goes.
Recap: I saw my consultant uroligist on the 1st February, was given an MRI scan on the 5th February and had my Biopsies done on the 8th February, all this based on a steadily rising PSA reading of 4.6, I'm 64 and based in the UK.
Well the biopsy itself was no problem at all, layed on my left side was given another DRE first, the procedure as far as I was concerned was pain free with just a little discomfort for about 2-3 mins when the ultrasound probe was first introduced and the 2 needle points were marked for the Lidacane to be injected.
Did not feel the lidacane being injected, and after that can honestly say I did not feel a thing when all the 12 biopsied cores were taken, other than a slight pinch as the core gun fired, so in real terms all OK.
Before my biopsies were taken, my MRI scan was normal with no lesions apparrent, also the ultrasound view was normal and six cores were taken from each side on biopsy.
Saw the consultant today the 16th February for Biopsy results, and one core on the left side showed Prostate Cancer, according to the report it's graded as a Adenocarcinoma with a Gleason score of 3+3=6, Grade One Group = 1 with Percentage of tissue involved by Tumor less than 5%
Now according to the consultant it is the lowest grade and least aggressive one I could have?
So what's step next, options were Prostectomy, Radiotherapy for 4 weeks, Brachyotherapy or active surveilance with PSA tests every three months and DRE at appointment with consultant and take it from there.
Too early to say what I'm going to do, but generally leaning at the moment to active surveilance until I can reaseach everything in detail.
So generally I'd say to people posting in these forums, don't ignore the facts in front of you and listen to your consultants advice and opinions when making your decision. It just goes to show when everthing feels and looks normal, it's not always what it seems and that curved ball is waiting in the background for you.
ES28567 Guest
Posted
Guest ES28567
Posted
No 1.5 Telsa, the hospital are currently installing a second MRI Scanner and that is also going to be a 1.5 Telsa machine.
charles61038 Guest
Posted
I had the same PSA ang Gleason numbers as you have, and also the same cancer cells - the adenocarcinoma. I was told that I had several treatment options and also could opt for active survailence. With your numbers, you have time to consider you options... and there are many. Everyone has to make their own disicsion as to what to do if anything. I am 65 and was diagnosed last year. After narrowing down my options, I decided on Brachytherapy. Mostly because it seemed like the least invasive and least amount of trouble, and with few side effects. The fact that with Brachytherapy, it is low dose radiation seed implants makes it much better as far as damage to surrounding tissues. And the best part is that it is a one time treatment and is done as an outpatient procedure. It takes about 45 minutes. I will go for my one year follow up next week. And I am feeling fine with no remaining side effects. I am off the Avodart and Flomax that I was put on in the begining... mostly as precaution because I was not having any issues or problems. The rise in PSA is what caused concern and the biopsy confirmed the prostate cancer situation. I figured I should get treatment and be cured while I am still in good health. The longer I wait, I may have other health issues to deal with - and I would be older too and may have a harder time of it. I wish you the best.
Guest charles61038
Posted
Thanks for your reply charles are you in the UK? Just out of curiosity how long did you do active surveilance for before you decided to have your treatment, and how quick was it organised after informing the consultant uroligist of your decision, also had your PSA level risen to alert you that maybe it's time to do something?
charles61038 Guest
Posted
I live in the U.S. - Texas. Actually, I was in a state of shock like I am sure many men are when they are first given the news of prostate cancer. I was first referred to a urlogist by my primary care doctor in June of 2016. That was due to my rising PSA. It had gone from 4.0, to 4.2, then to 5.2 and then 5.6. There were no other indications of problems. Nothing indicated by a DRE, or problems with urination. Even with the urologist, nothing abnormal with DRE exams. He first put me on antibiotics to see if that would lower my PSA. After that, my PSA went down from 5.6 to 5.1. And I thought that was a good sign. He said that was really not a good number still and suggested a biopsy. So I had that done in October of 2016. The biopsay confirmed the adenocarcinoma in two of the 12 core samples. 2% in one sample, 10% in the other. Gleason score was 3 + 3= 6. He said it was a slow growing type and that I had time to consider options - even active survailence. He said with the active survailence I would be checked every 3 to 6 months. He directed me to a couple of websites that discussed various treatment options. I looked at several. Then I met with an oncologist at the START CENTER. Dr. Ardow Ameduri. He was a great guy. He took the time to look at my situation, my numbers, my age etc. Then he put 3 choices before me that he said he would consider if it were him. They were: IMRT, (radiation treatment) Cyberknife, and Brachytherapy. Dr. Ameduri took his time with me to explain each treatment with it's side effects. I narrowed it down to Cyberknife and Brachytherapy. Cyberknife requried 4 or 5 markers to be inserted into the prostate to help guide the radiation beam for a more direct hit to where it was needed. It was going to require 5 sessions lasting 45 minutes each. The Brachytherapy would be a one time treatment under anesthesia. A 45 minutes procedure. The low dose radiation would make the chance of damge to surrounding areas less. I finally decided on that treatment. There were some side effects in the beginning, but nothing servere. Radiation causes some inflammation to the urethra, but tylenol and/or ibuprofen helps with that. Also there was some frequency and urgency with urination for a while. But that gets less and less with time. The radiation (of any kind) causes some fatigue, but not all the time. When it causes you to feel fatigued, you just have to rest and let your body recover. After about 4 months (which is about the half life of the radiation), things start to improve quickly. I am not at the one year point, and it is like nothing happened. Urination is back to normal, getting up at night maybe once if at all. Sexual function is back to normal too. At least you have time on your side to consider your options. I can point you to some informative websites if you like... or I would answer any questions that I can.
terryw
Posted
Glad to hear your results. It certainly sounds as if you have a slow growing tumour which is never going to cause you any problems or need any treatment. Good result.
All the best Terry
Guest terryw
Posted
Kind regards
memmawhite terryw
Posted
Hello Terry,
Too bad I did not zero in on your post earlier than now. I am only 63 and I coudn't agree with you more. According to the statistics, you mght die of other causes before the prostate cancer kills you anyway. I was unaware of these facts, that the cancer detection rate through biopsies is only about 20%, prior to allowing my urologist to lure me into undergoing a biopsy. Althouth the detection rate is even higher than your quoted 3 out of 100, it is still a low hit rate to justify relying on bipsies, considering the adverse consequencies. If I knew what I know now, I would never have submitted to this medieval procedure.
I am not been insensitive to the real agony experienced by those who have been troubled by the disease. This is life and what counts in the end is how we lived and what we lived for. Life is terminal for all of us and should be no reason to refrain from bringing the clear light of reason to bear on issues of life and death. Personally, life is more humdrum without the ability to express love for another through the intense emotional attachment that is ultimately sexual. After my two biopsies, I lost all sensouness and was no longer capable of attaining spontaneous erections. Hedonism aside, I enjoy sexual relations and the thought that I can no longer indulge in that activity takes away the real zest for life. If I have to advice anyone contemplating this procedure, my answer would be this. Would it matter to you if you can no longer express love to your wife or can do only do so through intense and frustrating struggle, relying on gadgets and torturous treatments that hardly work like the real thing? Would your quality of life remain unchanged if you can no longer admire random beauty as you wander around this earth or express emotion at sight of the virtually angelic beings that shape our fantasies?
My half brother died of prostate cancer but I realized that it does not mean that I would die of the same cause. And even if I did, it is not as if I am supposed to live forever, so what? I like living but I am not afraid to die. In fact, I am more afraid of not been able to enjoy living! When my brother died, he died with a smile on his face. He left behind (hold on to your seat) more than fifty adult offspring. At least, he could afford it.
I mention this because my doctor used the threat of iminent death to lure me into surgery. When I consulted a second doctor, he told me that he would not have biopsied me with a 3.3 PSA. That is why I now regret the decision to allow my previous doctor to walk through my mind with his dirty feet. Today, I am PSA free. I did it through changing my habits. I quit alcohol entirely and I ingest only foods that are plant based. Of course, I consume chicken, turkey and fish but no red meat. That means, no processed foods ever, except when my wife and I dine out 3 or 4 times a year.
I am not against prostrate cancer per se. The decision to refuse a biopsy is no doubt a very difficult one because man is constructed to cling on to this life my any means necessary. But, as has been documented, many of us die of other causes without even knowing that we have prostate cancer. But, this is an unnecesasry test that one should undergo only when there are unmistakeable signs that the disease exists. It should never be undertaken as a fishing expedition, which is how the present treatment protocols recommend. In fact, as mentioned by Eddie775, there is a new screening technique at UCLA in Southern Calfifornia, which combines enhanced MRI imaging to first detect the site of the cancer before targeting it for biopsy. If signs of cancer are not evident, there will be no biopsy.
One thing you should note is that hospitals and urologists are good at giving vague explanations. As a practitioner in forensic accounting, I notice the prevalence of this type of behavior in leaders and professionals in positions of authority. Your best bet is to elicit information from various sources to form your own opinions, which can be very hard because you happen to be in the middle of it. Wishing you the best of luck in this thing. Hopefully, you will find as good a doctor as Whiteplume did. You're probably safe with a really good doctor but they are very rare!
terryw memmawhite
Posted
Hi Memmawhite
Sorry to hear about your problem - hope things get back to normal as soon as possible.
Your psa was certainly low for a biopsy at your age - unless you had symptoms of some sort?
Personally I am following my own version of watchful waiting, which doesn't involve biopsies or doctors. I have no family history of pca, no symptoms, and a psa which is slightly raised but fairly static and probably due to BPH causing a slightly enlarged prostate.
When I get some symptoms which cause me to change my mind then I'll see a doctor and if necessary get a biopsy. By then it may be too late, but I've made my own decision and I'll face the consequences, if any. In the meantime I'll get on with my life my way. If I have pca - and I may well have - my estimation is that it is likely to be slow developing, and if it isn't bothering me I don't see why I should bother it. When you come down to it pca is just a bunch of cells. If they were threatening my life it would be sensible to do something about them, but otherwise they don't bother me.
I wish you all the best and hope things work out.
Terry
rolf61809 terryw
Posted
my heart is definitely off to you sir you have certainly done your homework. I am 61 and my circumstances are quite similar to yours. over the past three years my PSA has been between 5 and 7 going up or down sometimes. I did my homework and determined that a 3T MRI would be a good first step before I blindly had a shotgun approach biopsy. the results of that was a pirads score of 3 which is somewhat indeterminate though they did identify a couple possible lesions. the urologist I was seeing at that time was against having a fusion biopsy which I understand is the way to go. I verified this by seeing a couple urologists at the Cleveland Clinic in Ohio. so if my PSA does rise significantly I will have to get another 3T MRI since it has been quite a while since the last one and then get a targeted Fusion biopsy. some doctors just can't handle the fact that you can do your own research and come up with conclusions that are diametrically opposed to what they want to tell you. my local urologist even had the unmitigated Gall to tell me that I should stay off the internet.
terryw rolf61809
Posted
Hi Rolf
Good to hear from you. Stay off the internet!? They haven't to that one here in the UK yet - they're still just saying stay off the fags and booze. (I haven't taken any notice of that either).
You're right of course, many doctors just aren't keen on informed patients who want to make their own decisions.
I keep reading about new tests and procedures being developed but it is likely to be years before our cash-strapped and conservative National Health Service will be offering any of them. Too late for me no doubt, but hopefully available to the next generation.
It's interesting that the responsible body in the UK came out several months ago saying that guys should have an MRI before a biopsy, yet some of your countrymen have been posting on here for years that they wouldn't consider a biopsy without having an MRI first, I don't suppose UK doctors will change that fast though, and no doubt I would be regarded as a really awkward customers if I went into some NHS hospitals and tried to insist on having an MRI first!
Overall you are definitely in the right place when it comes to prostate diagnosis and treatment.
I wish you all the best,
Terry
john52204 terryw
Posted
Hello Terry i had the Biopsy 2 weeks ago like you i was concerned but in all i wanted
to know the results "cancer or not" so i went ahead it is not painful just bit intrusive.
the main problem is after the biopsy you get problems with constipation so get some
Fibogel and stuff to help you ,it is most important you do not force ,just take your
time .it was 3 days before i could use toilet .hope this helps
terryw john52204
Posted
Glad your biopsy went fairly well. I hope the result is good
All the best Terry